Asian American Mental Health Disparities & Cultural Psychiatry March 2015 Shuo (Sally) He, MD MPH PGY-2 Discussant: Su Yeon Lee, Ph.D. Policy Analyst Office for Research on Disparities and Global Mental Health National Institute of Mental Health

● Health & healthcare disparities ● Asian American mental health

o Prevalence/rates o Roles of stigma & discrimination o Mental health underutilization

● Cultural considerations in treatment of depression among Chinese Americans

● Public health & policy considerations

Outline

● Caution with overgeneralization ● Individual experiences and identities

also important ● Caution with comparison between

different racial/ethnic groups ● Chinese American is not the same

population as Chinese living in China

But first...

Health Disparities

Definition:

● “Health disparity” - refers to a higher burden of illness, injury, disability, or mortality experienced by one population group relative to another group

● A “health care disparity” - refers to differences

between groups in health coverage, access to care, and quality of care.

Source: Disparities in Health and Health Care: Five Key Questions and Answers. (n.d.). Retrieved February 23, 2015, from http://kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/

● Race o Not biological, but a social category (i.e. Asian & Pacific

Islander Americans)

● Ethnicity o Refers to a common heritage (include history, language,

rituals, preferences for music & food) shared by a particular group (Native Hawaiians vs. Vietnamese Americans)

Source: Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug.

Definition:

Winker (2004): ● Measuring race is initial step ● Is important indicator of health disparities and health

care delivery - different quality of care ● Poor proxy for unmeasured confounders, like cultural,

social, environmental influences ● Researchers should define how race is measured, by

whom, and why

Should race/ethnicity be measured?

Source: Winker, M. (2004). Measuring Race and Ethnicity: Why and How? JAMA: The Journal of the American Medical Association, 1612-1614.

Why Health Care Disparities Matter ● Racial/ethnic minority

o are growing population o are less like to have access to available mental

health services and to receive needed mental health care

o often receive poorer quality of care o significantly under-represented in mental health

research Source: New Freedom Commission. (n.d.). Retrieved February 24, 2015, from

http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/New_Freedom_Commission/Goal_3_Disparities_in_Mental_Health_Services_Eliminated.htm

Why Health Care Disparities Matter

● Racial/ethnic minorities also experience o Mistrust & fear of treatment o Different cultural ideas about illnesses and health o Differences in help-seeking behaviors, language, and

communication patterns o Racism, discrimination by individuals and institutions o Varying rates of being uninsured

Source: New Freedom Commission. (n.d.). Retrieved February 24, 2015, from http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/New_Freedom_Commission/Goal_3_Disparities_in_Mental_Health_Services_Eliminated.htm

Why Health Care Disparities Matter ● Estimates that 30% of direct

medical costs for Blacks, Hispanics, and Asian Americans are excess costs due to health inequities

● Loses an estimated $309 billion per year due to direct and indirect costs of disparities

● Estimates include self reported mental-health status

Source: Disparities in Health and Health Care: Five Key Questions and Answers. (n.d.). Retrieved February 23, 2015, from http://kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/

Asian American Mental Health

● Misperception that Asian Americans are well adjusted and thriving in the US

● Overlooks variations in differences within Asian Americans

● Cost of aspiring to succeed academically may deteriorate parent-child relation and increase likelihood of anxiety/depression

● Model minority label creates social isolation (can lead others to misunderstand or alienate them)

Model Minority Myth:

Kwok, J. (2013). Factors That Influence the Diagnoses of Asian Americans in Mental Health: An Exploration. Perspectives in Psychiatric Care, 288-292.

● > 320 million = total US census ● 17.3 million = estimated number of U.S. residents of Asian descent

(2010) ● 46% percentage growth = of Asian alone or in combination (2000-

2010)

● Chinese-Americans were the largest Asian group (3.8 million in 2009), followed by Filipinos (3.2 million), Asian Indians (2.8 million), Vietnamese (1.7 million), Koreans (1.6 million) and Japanese (1.3 million).

Asian American Population

United States Census Bureau. (2011). Retrieved February 27, 2015, from https://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb11-ff06.html

Asian category consist of about 43 different ethnic groups and >100 different languages and dialects

Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug. Chapter 5 Mental Health Care for Asian Americans and Pacific Islanders. Retrieved February 24, 2015, from http://www.ncbi.nlm.nih.gov/books/NBK44245/?report=reader

Asian American Mental Health:

How many are affected?

Percentage of Adults Reporting Poor Mental Health by Race/Ethnicity

Location White Black Hispanic Asian/Native Hawaiian & Pacific Islander

American Indian/Alaska Native

Other

United States

35% 36.5% 36.8% 32.2% 42.1% 43.7%

DC 36.2% 39.5% NSD NSD NSD NSD

NY 37.1% 41.8% 40.9% 33.9% NSD NSD

Data represents adults who reported that their mental health was “not good” between one and 30 days in the past 30 days. NSD = Not sufficient data

Kaiser Family Foundation. (2013, January 1). Percent of Adults Reporting Poor Mental Health by Race/Ethnicity. Retrieved February 24, 2015, from http://kff.org/other/state-indicator/poor-mental-health-by-re/

Prevalence of Current Depression by Type Among US Adults by Selected Characteristics, 2006 and 2008

n Major depression % (95% CI)

Other depression % (95% CI)

Any depression % (95% CI)

Total 235,067 4.1 (3.9-4.2) 5.2 (4.9-5.3) 9.1 (8.9-9.4)

Race/Ethnicity White, non-hispanic Black, non-hispanic Hispanic Other, non-hispanic

183,563 17,604 18,391 13,528

3.7 (3.6-3.9) 5.0 (4.5-5.6) 4.7 (4.1-5.4) 5.1 (4.4-6.0)

4.2 (4.1-4.4) 7.9 (7.1-8.8) 7.0 (6.2-7.8) 5.6 (4.8 - 6.5)

8.0 (7.7-8.2) 12.9 (11.9-14.0) 11.7 (10.8-12.7) 10.7 (9.6-11.9)

Other = Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, multirace

CDC. (2013, October 4). Depression. Retrieved February 24, 2015, from http://www.cdc.gov/mentalhealth/data_stats/depression.htm

Where’s the data?

● NLAAS o National sample, face-to-face interview (or telephone) in

different languages (English, Chinese, Spanish, Tagalog, Vietnamese)

o DSM-IV-TR criteria: anxiety, mood disorder, depressive disorder, substance use disorder

Prevalence of Mental Health Disorders by Gender and Nativity

Hong, S., Walton, E., Tamaki, E., & Sabin, J. (2014). Lifetime Prevalence of Mental Disorders Among Asian Americans: Nativity, Gender, and Sociodemographic Correlates. Asian American Journal of Psychology, 5(4), 353-363.

Hong, S., Walton, E., Tamaki, E., & Sabin, J. (2014). Lifetime Prevalence of Mental Disorders Among Asian Americans: Nativity, Gender, and Sociodemographic Correlates. Asian American Journal of Psychology, 5(4), 353-363.

Summary of study by Hong et al. (2014 ): ● Ethnically include Vietnamese, Filipino, Chinese and “Other Asian”

(N=2095) ● Lifetime prevalence of any mental disorder was 18.1% ● In total sample, most prevalent class of disorders:

o anxiety disorder (10.2%) o mood disorder (9.5%) o and substance use disorder (4.0%)

● Within disorder classes, most prevalent were o MDD (9.1%) o Social phobia (5.3%) o Alcohol abuse (3.4%)

● Men had significantly higher rates of lifetime substance use disorder

(alcohol and drug abuse) ● Rates of any mood disorders for U.S. born women were

significantly higher than all other groups ● Rates of any anxiety disorders for U.S. born women were

significantly higher than immigrants o Panic disorder (5.5 %) o Social phobia (8.0 %) o PTSD (5.7%)

Higher Rates of Mental Health Disorders Associated with Other Socioeconomic factors: a. Anxiety disorder - among immigrant men: older age, poor/fair English proficiency

a. Mood disorder

i. Among Immigrant women-young, never married ii. Among immigrants - men and women who never married iii. Among US born men and women - widowed/separated/divorced iv. Immigrant men- with low household incomes or poor/fair English proficiency v. Among US born - Chinese women (vs. Filipino and other Asians)

a. Substance use disorder - never married; immigrant men with HS degree

a. Any mental disorder - youngest age, immigrant women; immigrant women and US

born men who have never married ; Chinese US born women; immigrant men who spoke poor/fair English

Hong, S., Walton, E., Tamaki, E., & Sabin, J. (2014). Lifetime Prevalence of Mental Disorders Among Asian Americans: Nativity, Gender, and Sociodemographic Correlates. Asian American Journal of Psychology, 5(4), 353-363.

Mental Health Disorders by Subethnic Groups Su Yeon Lee et al. (2014)

● Survey of noninstitutionalized participants >=18 yrs old from NESARC (National Epidemiologic Survey on Alcohol & Related Conditions

● NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule- DSM-IV (AUDADIS-IV).

● Asian subsample (N=1,431) o East Asians (China, Japan, Korea, Taiwan) (n=648) o Southeast Asians (Indonesia, Malaysia, Vietnam, Thai, Laos,

Cambodia, Burma, Pacific Islands) (n=495) o South Asian (India, Afghanistan, Pakistan, Iran) (n=298)

Lee, S., Martins, S., & Lee, H. (2014). Mental Disorders and Mental Health Service Use Across Asian American Subethnic Groups in the United States.Community Mental Health Journal, 153-160.

Southeast Asians had ■ a higher prevalence of any DSM-IV psychiatric disorders (34.6

%) compared to East Asians (22.5 %) and South Asians (24.5 %)

■ highest prevalence of substance use disorders (16.7 %), mainly due to their higher prevalence of drug use disorders (15.5 %) compared to East Asians (10.2 %) and South Asians (10.4 %; p = 0.02)

South Asians had the lowest prevalence of substance use disorders (11.1 %) followed by East Asians (13.1 %; p = 0.06).

Mental Health Disorders by subethnic groups

Prevalence of Depression among Chinese Americans ● Sample

o 1993-1994 survey 1,747 Chinese American households in Los Angeles area

● Measurements o translated University of Michigan’s Composite International

Diagnostic Interview into Chinese ● Findings

o Major depression episode lifetime: 6.9%, in the past 12 months: 3.4%

o Lifetime rate of dysthymia: 5.2%, with 0.9% in the past 12 months

Takeuchi, D. (1998). Lifetime and Twelve-Month Prevalence Rates of Major Depressive Episodes and Dysthymia Among Chinese Americans in Los Angeles. The American Journal of Psychiatry, 155(10), 1407-1414.

Asian American Mental Health:

Role of Stigma

● Definition of stigma: o Refers to negative and discrediting markers that society

attributes to people who are different, in the context of social, political, cultural factors and standards of which individuals have little control (Goffman, 1963)

Chung, H. (2002). The challenges of providing behavioral treatment to Asian Americans. The Western Journal of Medicine, 176, 222-223. Retrieved February 1, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071732/pdf/wjm17600222.pdf

Conceptual Model of Stigma

Bos, A., Pryor, J., Reeder, G., & Stutterheim, S. (2013). Stigma: Advances in Theory and Research. Basic and Applied Social Psychology, 1-9.

Stigma in Asian American communities ● Asian American communities feel even more stigmatized by mental

illness ● Many believe that mental health disorders are due to lack of willpower ● It is shameful to seek help or admit that one has mental health

problem ● To preserve the family name and save “face,” may often look first to

families for help than admit their problems to a stranger → intense family involvement but longest delay in seeking mental health care → may turn patient over to facility and disengage when psychiatric help is finally sought

Kwok, J. (2013). Factors That Influence the Diagnoses of Asian Americans in Mental Health: An Exploration. Perspectives in Psychiatric Care, 288-292.

Asian American Mental Health

Role of Discrimination

Role of discrimination

● Racial or ethnic discrimination o defined as unfair treatment received because of

one’s racial or ethnic characteristics o has been associated with variety of mental and

physical health outcome

● A literature review examine relationships between discrimination and Asian American health found that o Lack consistent, clear conceptual definition of

discrimination among 14 articles reviewed o Discrimination significantly associated with depressive

symptoms in 7 studies o Association between discrimination and physical health

(i.e. cardiovascular disease, respiratory condition, obesity, diabetes) in 3 studies

Impact of Discrimination on Mental and Physical Health

Nadimpalli, S., & Hutchinson, M. (2012). An Integrative Review of Relationships Between Discrimination and Asian American Health. Journal of Nursing Scholarship, 127-135.

Perceived Racism or Discrimination & Minority Health

Brondolo et al. (2011) ● 53% of the Asian participants, 54% of the Black participants, and 44%

of the Latino(a) participants had experienced race-related threat and harassment over the course of their lifetimes at least occasionally.

● No racial/ethnic group differences o in self-reported health o in symptoms of depression or anxiety

Brondolo, E., Hausmann, L., Jhalani, J., Pencille, M., Atencio-Bacayon, J., Kumar, A., ... Schwartz, J. (2011). Dimensions of Perceived Racism and Self-Reported Health: Examination of Racial/Ethnic Differences and Potential Mediators. Annals of Behavioral Medicine, 14-28.

Perceived Racism or Discrimination & Minority Health Brondolo et al. (2011) ● Significant association of lifetime exposure to perceived

discrimination (subscales of social exclusion and threat) with overall self-reported health among Asian Americans, African Americans and Latinos

● Depression, anxiety, cynical hostility all positively associated with discrimination, negatively associated with self-reported health

Effect of discrimination on mental health service use among Chinese Americans

Spencer et al. (2004) ● Chinese American Psychiatric Epidemiological Survey - strata-

cluster survey (1993-1994) in LA (n=1747) ● Measured discrimination

o Race discrimination - having ever been treated unfairly or badly because of one’s race/ethnicity

o Language discrimination - treated unfairly or badly because “you speak a different language or you speak with an accent”

Spencer, M., & Chen, J. (2004). Effect of Discrimination on Mental Health Service Utilization Among Chinese Americans. American Journal of Public Health, 809-814.

Effect of discrimination on mental health service use among Chinese Americans ● Measured psychiatric disorder:

o University of Michigan version of the Composite International Diagnostic Interview.

o Computer algorithms are used to construct clinical diagnoses o limited analyses to affective disorders and anxiety disorders.

● Measured mental health utilization: o a) use of formal services, o b) use of informal services (i.e. minister, priest, temple,

spiritualist, herbalist, or fortune-teller), and o c) seeking help from friends or relatives.

Effect of discrimination on mental health service use among Chinese Americans

● Race discrimination: 18% of respondents reported having been treated badly or unfairly because of their racial/ethnic status

● Language discrimination: 13% reported such treatment because they speak a different language or speak with an accent

2.2 more likely to use informal services and 2.4 more likely to seek help from friends or relatives compared to those who did not report such treatment

Spencer, M., & Chen, J. (2004). Effect of Discrimination on Mental Health Service Utilization Among Chinese Americans. American Journal of Public Health, 809-814.

Asian American Mental Health Disparity

Mental Health Underutilization

Health Care Disparities in Utilization

● Low admission rates to state hospitals and low utilization of outpatient mental health services

● Initially thought as “model minority” - but Asian patients had more severe and chronic conditions o Did not reach service system until very late in the help

seeking process o Asian patients with schizophrenia typically contained within

the family and community, generally did not reach the mental health system until 3 yrs after initial onset of psychotic symptoms

Lin, K., & Cheung, F. (1999). Mental Health Issues for Asian Americans.Psychiatric Services, 50(6), 774-780.

NLAAS data

● Findings o Asian Americans have lower rates of mental health-related

service use (8.6%) compared to the general population (17.9%) o Lower percentage of Asian Americans (34.1%) who had a

probably DSM-IV diagnosis during a 12-month period sought any service compared with counterparts (41.1%)

o US-born individuals used mental health services at higher rates than did immigrants.

Abe-Kim, J., Takeuchi, D., et al. (1997). Use Of Mental Health-Related Services Among Immigrant And US-Born Asian Americans: Results From The National Latino And Asian American Study. American Journal of Public Health, 91-98.

Mental Health Underutilization among Asians Su Yeon Lee et al. (2011) ● National sample of survey of noninstitutionalized participants

>=18 yrs old from NESARC (National Epidemiologic Survey on Alcohol & Related Conditions

● Aim: compare lifetime mental health service utilization among Asians to that of other racial/ethnic groups (whites, blacks, Hispanics)

● Diagnosis = Alcohol Use disorder and Associated Disabilities Interview Schedule DSM-IV (AUDADIS-IV) for mood disorder, anxiety disorder, alcohol use

● Mental health service utilization = outpatient services, inpatient services, emergency services, use of prescribed medication

Mental Health Underutilization among Asians

Lee, S., Martins, S., Keyes, K., & Lee, H. (2011). Mental Health Service Use by Persons of Asian Ancestry With DSM-IV Mental Disorders in the United States. Psychiatric Services, 1180-1186.

● Proportion of Asians making use of mental health services for mood or anxiety disorder was lowest among the racial/ethnic groups

● Asians with lifetime diagnosis of mood disorder were

significantly less likely to use mental health services for the disorder than whites, Hispanics, and Native Americans but equally likely as blacks after adjustment for socioeconomic factors and severity of mood disorder

Summary of Study:

Lee, S., Martins, S., Keyes, K., & Lee, H. (2011). Mental Health Service Use by Persons of Asian Ancestry With DSM-IV Mental Disorders in the United States. Psychiatric Services, 1180-1186.

Mental Health Service Use Across Asian American Subethnic Groups Su Yeon Lee et al. (2014) ● Goal: examine the differences in mental health needs and patterns of

mental health service use across 3 Asian American subethic groups (East Asian, Southeast Asian, South Asian) using NESARC

● Findings: o SE Asians had higher prevalence of overall psychiatric

disorders compared to East Asians & South Asians, mostly due to a high prevalence of drug use disorders

o East Asians had a significantly lower odds of mental health service use (OR=0.25 CI = 0.08=0.84) compared to South Asian

SE Asians = (Indonesia, Malaysia, Vietnam, Thai, Laos, Cambodia, Burma, Pacific Islands) East Asians = (China, Japan, Korea, Taiwan)

Racial & Ethnic Differences in Depressive Subtypes

Su Yeon Lee et al. (2013) ● Aim: examine the relationship between subtypes of

depressive symptoms and mental health service use across racial/ethnic groups based on survey

● Depressive subtypes ○ mild, cognitive, psychosomatic, severe

Lee, S. (2014). Racial andethnic differencesin depressive subtypes and access to mental health care in the United States. Journal of Affective Disorder, 155, 130-137.

Four depressive subtypes: 1. “mild” (i.e., lower probabilities of endorsing all depressive symptoms) 2. “cognitive” (i.e., high probabilities of endorsing worthlessness and concentration difficulties) 3. “psychosomatic” (i.e., high probabilities of endorsing sleep, fatigue, and impaired concentration), 4.“severe” (i.e., high probabilities of all depressive symptoms).

Racial & Ethnic Differences in Depressive Subtypes

Behavioral Model of Health Service Utilization

Rebhan, D. (n.d.). Health Care Utilization: Understanding and applying theories and models of health care seeking behavior. Retrieved February 24, 2015, from http://www.cwru.edu/med/epidbio/mphp439/healthcareutil.pdf

Barriers to Health Utilization ● Demographic factors

o Acculturation, Nativity (Immigrant vs. US-born, or Generation), English proficiency, Legal immigration status, Poverty Rate

● Cultural factors o Stigma, loss of face, causal beliefs; Perceived stigma/discrimination o Lack of awareness or understanding of services o Some may somaticize mental health problems or underreport

symptoms ● System issues

o Poor culturally responsive services o Limited access to care (cost, lack of insurance, location)

Cultural Considerations in treating Chinese Americans

Clip from Practicing Cultural Psychiatry in San Francisco’s Chinatown https://www.youtube.com/watch?v=8NrJPxNexvw (5:10 - 5:59)

Above photo Courtesy: http://accidentalchinesehipsters.tumblr.com/

Different Cultural Models Western Culture Eastern/Chinese Culture

Shared clinical decision-making model that emphasizes patients’ autonomy and encourages them to act as full participants in the treatment process. Individualism, autonomy, independence Biomedical model - isolable disease processes (depression: neurotransmitter deficiency, unresolved psychic conflict, distorted thought patterns) Dualistic distinction between mind and body

Clinicians expected to ‘protect’ patients from psychiatric diagnosis - viewed with great fear and shame Family involvement and interdependence Chinese medical model - patterns of harmony/disharmony, interpret symptoms within a larger context (Qi, Yin Yang, 5 organ systems) No distinction between mind and body

Caution with overgeneralization!

Some traditional beliefs ● Confucian: family is important; negative emotion harmful to

social fabric ● Taoism: distress is part of life, not to be fought, but to be

understood and harmonized

Buddhist meditation: detach from negative emotions and transcend them; isolate grief, fear, hostility, negative affect

● Traditional Chinese Medicine: Yin-Yang balance, and 5

Phases of the body (Wood=Liver, Earth=Spleen, Water=Kidney, Fire=Heart, Metal=Lungs)

Excess anxiety ● related to stagnation in the Spleen organ Qi ● also associated with abdominal symptoms such as distention and

poor digestion Sadness and grief ● can weaken the Lung essence, which in turn can lead to a pale

complexion and a weak voice -Anxious or depressive feelings can be in excess or deficient, and will disturb the balance of Qi within the person. -States are not in and of themselves conceptualized as disease entities

Some Traditional Chinese Medicine beliefs

Yeung, A., & Kam, R. (2008). Ethical and Cultural Considerations in Delivering Psychiatric Diagnosis: Reconciling the Gap Using MDD Diagnosis Delivery in Less-Acculturated Chinese Patients. Transcultural Psychiatry,531-552.

● “Endure” = 忍 (ren) ● “Save face” - signifies a desire or strategy to avoid

humiliation or embarrassment, to maintain dignity or preserve reputation

Some Cultural Concepts

Somatization

Yeung et al. (2004)

● Examine illness beliefs of depressed Chinese Americans in primary care in Boston

● May 1998-Nov 1999 ● Screened for depression using

Beck Depression Inventory (CBDI)

● Majority (n=22, 76%) of depressed Chinese Americans complained mainly of somatic symptoms

Yeung, A., Chang, D., Gresham, R., Nierenberg, A., & Fava, M. (2004). Illness Beliefs of Depressed Chinese American Patients in Primary Care. The Journal of Nervous and Mental Disease, 324-327.

Reasons for somatization

● Stigma attached to psychiatric symptom, compared to relative acceptance of physical complaints

● Societal pressure to suppress and disguise negative feeling states

Somatization ● Leads to inadequate treatment of psychiatric

disorders ● When depressed Chinese Americans are

asked explicitly, they readily report their depressive symptoms without difficulty

Obtaining History Engagement Interview Protocol (EIP) by Yeung et al. (2011) ● Integrate patients’ illness beliefs into

psychiatric assessment and evaluation ● Based on Kleinman’s questions, DSM-IV

Cultural Formulation model, and clinical experience

Yeung, A., Trinh, N., Chang, T., & Fava, M. (2011). The engagement interview protocol (EIP): Improving the acceptance of mental health treatment among Chinese immigrants. International Journal of Culture and Mental Health, 91-105.

EIP model ● Can be completed within 1 hour ● Effective to facilitate enrollment of patients in treatment of

depression ● Composed of 6 sections

1) history of present illness - include illness beliefs 2) psychosocial history 3) mental status exam 4) DSM-IV diagnoses 5) culturally sensitive disclosure of diagnosis 6) customized treatment negotiation

Disclosure of Diagnosis

Of the recent Chinese immigrants who met criteria for MDD in a clinic-based survey, a large majority (21/29, 72%) either did not know of the term MDD (you yu zheng) or did not consider it a diagnosable medical illness

Yeung, A., & Kam, R. (2008). Ethical and Cultural Considerations in Delivering Psychiatric Diagnosis: Reconciling the Gap Using MDD Diagnosis Delivery in Less-Acculturated Chinese Patients. Transcultural Psychiatry,531-552.

Communicating the diagnosis of MDD to less acculturated Chinese patients

● Process-based approach ● Involve family - understand illness narrative, family

dynamics, collaborate on treatment issues

Communicating the diagnosis of MDD to less acculturated Chinese patients

● Culturally sensitive use of Western psychiatric terms o Jing shen bing - ‘psychiatric disorder’ is synonymous with

craziness (refer to violent psychotic disorder and mental retardation)

o Xinli wenti - ‘psychological problem’ is less dramatic and refer to problems such as depression and anxiety

o Help understand depressive feelings as part of larger context of life struggles (not label it as ‘crazy’ or jing shen bing)

Communicating the diagnosis of MDD to less acculturated Chinese patients ● Translation of disorder is important to avoid stigmatized

connotations 1) MDD = zhong xing you yu zheng

= ‘severe depressive disorder’ 2) ‘Depressive disorder’ = you yu zheng or yi yu zheng

3)‘depression’ = you yu 4) avoid mental health jargon

Treatment negotiation of MDD

● Background from HPI o “What kind of treatment do you think you should receive?” o “What are the most important results you hope to receive

from the treatment?” ● Start by providing rationale for treatments - aimed to alleviate

suffering and reduce functional impairment ● Discuss available treatment options - provide rational,

pros/cons, side effects

Treatment negotiation of MDD

● Explore patient’s understanding, preference for medication treatment, counseling - clarify worries, misconceptions

● Medication - Chinese immigrants may consider treatment for the insane or question usefulness of medication for solving psychosocial problems.

● More familiar with ‘talk therapy’ or counseling (xin li fu dao) o refers to psychological guidance or coaching instead of

psychotherapy

Treatment negotiation of MDD to less acculturated Chinese patients

● Incorporate concepts from Traditional Chinese Medicine into Western models o i.e. explain “monoamine hypothesis” as an issue of

imbalance that disturb the “flow” of one’s life and emotional state (xinqing)

o antidepressant’s role is to restore the balance of the system, to tonify, and to strengthen energy of the brain (bu nao)

Summary ● Mental health disparities exist among Asian Americans

Limited data on a very diverse population Rates of mental health disorders varies by socioeconomic

factors (i.e. age, gender, marital status, US born vs. not, English proficiency)

Perceived stigma & racism/discrimination impact on health Mental health underutilization

● Diversity of Asian American population ● Incorporate patient’s explanatory model in HPI ● Be aware of using certain translated words in Chinese in explaining

diagnosis that might reduce or increase stigma

Bridging the gap: Policy implications ● Need for more research given diverse Asian American population ● Need to target specific demographic group -i.e.mood disorder among

young immigrant Chinese women ● Incorporate idea of cultural competency at a clinical level and not just

system level o As part of medical training curriculum o Increase interpreter's awareness of avoiding using certain

stigmatizing mental health terms ● Find ways to increase mental health utilization

o Address language barrier, discrimination, stigma o Integrate primary care and mental health services o Increase culturally appropriate mental health services

More resources: Resident’s Video Series http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.11b23 Center of Excellence for Cultural Competence: http://nyculturalcompetence.org/resources/

THANK YOU!

Guest speaker: Dr. Su Yeon Lee

Dr. Catapano, Dr. Khin Khin, Dr. Griffith, Dr. Norris Dr. Green, fellow residents

References Abe-Kim, J., Takeuchi, D., Hong, S., Zane, N., Sue, S., Spencer, M., ... Alegria, M. (1997). Use Of Mental Health-Related Services Among Immigrant And US-Born Asian Americans: Results From The National Latino And Asian American Study. American Journal of Public Health, 91-98. Brondolo, E., Hausmann, L., Jhalani, J., Pencille, M., Atencio-Bacayon, J., Kumar, A., ... Schwartz, J. (2011). Dimensions of Perceived Racism and Self-Reported Health: Examination of Racial/Ethnic Differences and Potential Mediators. Annals of Behavioral Medicine, 14-28. Bos, A., Pryor, J., Reeder, G., & Stutterheim, S. (2013). Stigma: Advances in Theory and Research. Basic and Applied Social Psychology, 1-9. CDC. (2013, October 4). Depression. Retrieved February 24, 2015, from http://www.cdc.gov/mentalhealth/data_stats/depression.htm Chung, H. (2002). The challenges of providing behavioral treatment to Asian Americans. The Western Journal of Medicine, 176, 222-223. Retrieved February 1, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071732/pdf/wjm17600222.pdf Disparities in Health and Health Care: Five Key Questions and Answers. (n.d.). Retrieved February 23, 2015, from http://kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/ Hong, S., Walton, E., Tamaki, E., & Sabin, J. (2014). Lifetime Prevalence of Mental Disorders Among Asian Americans: Nativity, Gender, and Sociodemographic Correlates. Asian American Journal of Psychology, 5(4), 353-363. Kaiser Family Foundation. (2013, January 1). Percent of Adults Reporting Poor Mental Health by Race/Ethnicity. Retrieved February 24, 2015, from http://kff.org/other/state-indicator/poor-mental-health-by-re/ Kwok, J. (2013). Factors That Influence the Diagnoses of Asian Americans in Mental Health: An Exploration. Perspectives in Psychiatric Care, 288-292.

Lee, S., Martins, S., & Lee, H. (2014). Mental Disorders and Mental Health Service Use Across Asian American Subethnic Groups in the United States.Community Mental Health Journal, 153-160. Lee, S., Martins, S., Keyes, K., & Lee, H. (2011). Mental Health Service Use by Persons of Asian Ancestry With DSM-IV Mental Disorders in the United States. Psychiatric Services, 1180-1186. Lee, S. (2014). Racial and ethnic differences in depressive subtypes and access to mental health care in the United States. Journal of Affective Disorder, 155, 130-137. Lin, K., & Cheung, F. (1999). Mental Health Issues for Asian Americans.Psychiatric Services, 50(6), 774-780. Nadimpalli, S., & Hutchinson, M. (2012). An Integrative Review of Relationships Between Discrimination and Asian American Health. Journal of Nursing Scholarship, 127-135. New Freedom Commission. (n.d.). Retrieved February 24, 2015, from http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/New_Freedom_Commission/Goal_3_Disparities_in_Mental_Health_Services_Eliminated.htm Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug. Chapter 5 Mental Health Care for Asian Americans and Pacific Islanders. Retrieved February 24, 2015, from http://www.ncbi.nlm.nih.gov/books/NBK44245/?report=reader Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug.

References

Rebhan, D. (n.d.). Health Care Utilization: Understanding and applying theories and models of health care seeking behavior. Retrieved February 24, 2015, from http://www.cwru.edu/med/epidbio/mphp439/healthcareutil.pdf Spencer, M., & Chen, J. (2004). Effect of Discrimination on Mental Health Service Utilization Among Chinese Americans. American Journal of Public Health, 809-814. Takeuchi, D. et al. (1998). Lifetime and Twelve-Month Prevalence Rates of Major Depressive Episodes and Dysthymia Among Chinese Americans in Los Angeles. The American Journal of Psychiatry, 155(10), 1407-1414. United States Census Bureau. (2011). Retrieved February 27, 2015, from https://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb11-ff06.html Winker, M. (2004). Measuring Race and Ethnicity: Why and How? JAMA: The Journal of the American Medical Association, 1612-1614. Yeung, A., Trinh, N., Chang, T., & Fava, M. (2011). The engagement interview protocol (EIP): Improving the acceptance of mental health treatment among Chinese immigrants. International Journal of Culture and Mental Health, 91-105. Yeung, A., Chang, D., Gresham, R., Nierenberg, A., & Fava, M. (2004). Illness Beliefs of Depressed Chinese American Patients in Primary Care. The Journal of Nervous and Mental Disease, 324-327. Yeung, A., & Kam, R. (2008). Ethical and Cultural Considerations in Delivering Psychiatric Diagnosis: Reconciling the Gap Using MDD Diagnosis Delivery in Less-Acculturated Chinese Patients. Transcultural Psychiatry,531-552.

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